Full Pre-Registration Logo
Language
  • English (US)
  • Español

  • IMEC Registration

  •  - -
  •  - -

  • We do no use your phone number for marketing purposes nor share it with third parties. You may opt out of texting by typing STOP at any time.

  • Health History

  •  - -
  •  

  • Review of Symptoms

    1. Please CHECK any persistent symptoms you have had in the past few months.
    2. READ through every section.
    3. If none of the symptoms apply to you, Check NO PROBLEMS.
    4. List other Concerns below.

  • I certify that the information on the Health History and Review of Symptoms forms is correct to the best of my knowledge. I will not hold my doctor or any members of his/her staff responsible for any errors or omissions that I may have made in the completion of this form.

  • Clear

  • To complete your registration online, please download and fill out the I-693 Form according to the instructions below. If you have trouble accessing this file or filling out the form, please contact Noemi at (408) 246-9926.

    • Click here, I-693 FORM, and download the PDF to your desktop.
    • Using Adobe, open it and fill out pages 1 and 2 ONLY.

    • DO NOT SIGN THIS DOCUMENT.

    • Upload your file here or print your document to bring to your appointment.

    • After uploading your document or printing your file, click SUBMIT to make
      your 1st Free Appointment to get started.
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof

  • Upon Submission, all your Registration records will be saved and secured.

  • Upon Submission, all your Registration records will be saved and secured.

  • Should be Empty: